Certificate Of Medical Necessity
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MISSOURI DEPARTMENT OF SOCIAL SERVICES MO HEALTHNET DIVISION
CERTIFICATE OF MEDICAL NECESSITY PATIENT NAME
PROCEDURE CODES (MAXIMUM 6)
PARTICIPANT MO HEALTHNET ID NUMBER
DESCRIPTION OF ITEM/SERVICE REASON FOR SERVICE
MOD MOD MOD MOD 1 2 3 4
MONTHS EQUIP. NEEDED (DME ONLY)
ATTENDING/PRESCRIBING PHYSICIAN NAME
ATTENDING/PRESCRIBING PHYSICIAN PROVIDER IDENTIFIER
DATE PRESCRIBED
PROGNOSIS
PROVIDER NAME AND ADDRESS
DIAGNOSIS
MO HEALTHNET PROVIDER IDENTIFIER
PROVIDER TAXONOMY CODE
PROVIDER SIGNATURE
MO 886-4377 (6-08)
PLEASE SUBMIT THIS FORM FOR EACH PROCEDURE REQUIRING DOCUMENTATION OF MEDICAL NECESSITY
DS1960 (6-08)
CERTIFICATE OF MEDICAL NECESSITY PATIENT NAME
PROCEDURE CODES (MAXIMUM 6)
PARTICIPANT MO HEALTHNET ID NUMBER
DESCRIPTION OF ITEM/SERVICE REASON FOR SERVICE
MOD MOD MOD MOD 1 2 3 4
MONTHS EQUIP. NEEDED (DME ONLY)
ATTENDING/PRESCRIBING PHYSICIAN NAME
ATTENDING/PRESCRIBING PHYSICIAN PROVIDER IDENTIFIER
DATE PRESCRIBED
PROGNOSIS
PROVIDER NAME AND ADDRESS
DIAGNOSIS
MO HEALTHNET PROVIDER IDENTIFIER
PROVIDER TAXONOMY CODE
PROVIDER SIGNATURE
MO 886-4377 (6-08)
PLEASE SUBMIT THIS FORM FOR EACH PROCEDURE REQUIRING DOCUMENTATION OF MEDICAL NECESSITY
DS1960 (6-08)
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